Early rehabilitation during extracorporeal membrane oxygenation has minimal impact on physiological parameters: A pilot randomised controlled trial.

BACKGROUND: Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to their severity of illness along with the care required to maintain the position and integrity of the ECMO cannula. Many patients on ECMO receive passive exercises, and rehabilitation is often delayed owing to medical instability, with a high proportion of patients demonstrating severe muscle weakness. The physiological effects of an intensive rehabilitation program started early after ECMO commencement remain unknown. OBJECTIVES: The primary objective of this study was to describe the respiratory and haemodynamic effects of early intensive rehabilitation compared with standard care physiotherapy over a 7-d period in patients requiring ECMO. METHODS: This was a physiological substudy of a multicentre randomised controlled trial conducted in one tertiary referral hospital. Consecutive adult patients undergoing ECMO were recruited. Respiratory and haemodynamic parameters, along with ECMO settings, were recorded 30 min before and after each session and continuously during the session. In addition, the minimum and maximum values for these parameters were recorded outside of the rehabilitation or standard care sessions for each 24-h period over the 7 d. The number of minutes of exercise per session was recorded. RESULTS: Fifteen patients (mean age = 51.5 ± standard deviation of 14.3 y, 80% men) received ECMO. There was no difference between the groups for any of the respiratory, haemodynamic, or ECMO parameters. The minimum and maximum values for each parameter were recorded outside of the rehabilitation or standard care sessions. The intensive rehabilitation group (n = 7) spent more time exercising per session than the standard care group (n = 8) (mean = 28.7 versus 4.2 min, p < 0.0001). Three patients (43%) in the intensive rehabilitation group versus none in the standard care group mobilised out of bed during ECMO. CONCLUSIONS: In summary, early intensive rehabilitation of patients on ECMO had minimal effect on physiological parameters.

The impact of venovenous extracorporeal membrane oxygenation on cytokine levels in patients with severe acute respiratory distress syndrome: a prospective, observational study.

OBJECTIVE: The immunoinflammatory response is central to the pathogenesis of acute respiratory distress syndrome (ARDS). However, little is known how this is affected by venovenous (VV) extracorporeal membrane oxygenation (ECMO). Our objective was to investigate the factors that influence the inflammatory response of patients with ARDS undergoing VV ECMO, and to analyse the impact of this response on hospital mortality. DESIGN AND SETTING: A prospective observational study of all consecutive patients with severe ARDS who had VV ECMO at a tertiary German ECMO centre from 2009 to 2015. Patients without complete datasets were excluded. Cytokines (interleukin [IL]6, IL8 and tissue necrosis factor [TNF]α) and inflammatory markers (white cell count and C-reactive protein) were assessed before ECMO initiation and on Days 1, 5 and 10, before explantation and at explantation. RESULTS: A total of 262 adult patients undergoing VV ECMO were analysed. Their median Sequential Organ Failure Assessment score was 12, PaO2/FiO2 ratio was 64 mmHg, and overall in-hospital mortality was 34%. Cytokine levels fell quickly within 24 hours and fell further over the first 5 days. Extra-pulmonary ARDS was associated with higher IL6 and IL8 levels compared with pulmonary ARDS. Mechanical ventilation with positive end-expiratory pressure ≥ 15 cmH2O before ECMO was associated with higher IL6, IL8 and TNFα levels. Driving pressures ≥ 19 cmH2O before ECMO were associated with higher IL8 levels. Non-survivors had higher IL6 and IL8 levels for the duration of ECMO. CONCLUSION: Cytokine levels, on average, fall rapidly after initiation of VV ECMO, which may be related to the reduction of invasiveness of mechanical ventilation. Higher cytokine levels are associated with extrapulmonary causes of ARDS, more aggressive mechanical ventilation before VV ECMO, and mortality.

Computer based haemodynamic guidance system is effective and safe in management of postoperative cardiac surgery patients.

A circulatory guidance system, Navigator, was evaluated in a prospective, randomised control trial at six Australian university teaching hospitals involving 112 scheduled postoperative cardiac surgical patients with pulmonary artery catheters placed and receiving 1:1 nursing care. The guidance system was used to achieve and maintain physician-designated cardiac output and mean arterial pressure targets and compared these with standard post open-heart surgery care. The primary efficacy endpoint was the standardised unsigned error between the targeted and the actual values for cardiac output and mean arterial pressure, time averaged over the duration of cardiac output monitoring - the average standardised distance. This was 1.71 (SD=0.65) for the guidance group and 1.92 (SD=0.65) in the control group (P=0.202). Rates of postoperative atrial fibrillation, adverse events, intensive care unit and hospital length-of-stay were similar in both groups. There were no device-related adverse events. Guided haemodynamic therapy with the Navigator device was non-inferior to standard intensive care unit therapy. The study was registered with ClinicalTrials.gov Identifier NCT00468247.